Retreat Application

FMZO National One Day Retreat

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National FMZO Retreat April 18, 2015 - 9 AM to 4 PM *

Half Day Whole Day

If you are taking precepts please fill in the following

Guiding Teacher *

[Note: Participants may find some aspects of the retreat physically or emotionally demanding. In order to help maintain a safe environment for you and others, we ask the following questions. The following information will be kept confidential. It is requested solely in the event of an emergency.]

Do you have any known physical or mental condition that could affect your ability to participate in the retreat? *

If your answer is yes, please summarize briefly, and, if applicable, provide the name of your health care practitioner who we may contact in the event of an emergency:

If Applicable

Health Care Contact *

Please list any critical medications you take on a regular basis, and dosages:

Critical Medications *

Please list any critical food, drug, or environmental allergies you may have: *

RELEASE

Participants may find some aspects of the retreat program physically or mentally demanding. The program does include physical work and a vigorous daily schedule. I may freely decline to participate in any work that in my sincere judgment is dangerous to my health. I realize that I may consult with a teacher at any time to resolve any difficulties I might have. I will not leave the retreat grounds during the program without consulting with a teacher.

I agree to release Five Mountain Zen Order and Ocean Eyes Zen Center from liability from any injury I suffer and to indemnify the same for any injury to others caused by me. By entering your full legal name you are signing this document.

How would you rate your physical health: good, fair or poor? (please select one) *

In case of accident or serious illness, whom should we notify? *

Relative/Other's Name *

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Signature (Enter Full Legal Name) *

Submit

F﻿MZO National One Day Retreat﻿

If you are taking precepts please fill in the following

[Note: Participants may find some aspects of the retreat physically or emotionally demanding. In order to help maintain a safe environment for you and others, we ask the following questions. The following information will be kept confidential. It is requested solely in the event of an emergency.]

RELEASE

Location

FMZO National One Day Retreat